Fluid Restriction Not Followed for a Resident: A resident with CHF, ESRD, and respiratory failure was on an 1800 ml fluid restriction, but nursing, dietary, and nursing aide documentation showed the resident received more fluid than allowed on multiple days. The MAR documented nursing fluids, the tray card documented dietary fluids, and a fluid tracking form documented additional fluids, but the totals were not combined in the record review, and the resident consumed amounts above the ordered restriction.
Failure to monitor and document fluid restriction intake led to two residents receiving fluids outside ordered limits. One resident with CHF had a 2000 mL/day fluid restriction, but a water pitcher was kept at bedside, the diet slip did not reflect the restriction, and nursing and dietary communication was inconsistent. Another resident with hyponatremia had a 1500 mL/day free water restriction, yet bedside pitchers and visitor-provided water were observed, shift totals were not calculated into 24-hour intake, and the record showed no documentation of education or provider notification when the restriction was exceeded.
Failure to monitor and address significant weight loss. Two residents had documented nutritional risk and ongoing weight loss, but weights were not consistently obtained or reviewed, and the RD did not identify or add further interventions. One resident with orthopedic aftercare and UTI lost 11% in one month with low protein and albumin labs, while another resident with MI, HF, and depression lost 12.3% over 73 days despite a soft diet and supplemental shakes. Staff and the RD acknowledged the weight loss, but no additional nutritional assessments or interventions were identified.
Failure to monitor and address nutritional needs led to weight loss and poor meal intake for four residents. One resident with ESRD on dialysis, DM2, malnutrition, and swallowing complaints refused a sugary supplement and lost significant weight; another resident with dementia and malnutrition could not manage utensils and lost weight; a resident with dementia and hearing loss struggled to eat because staff did not assist promptly and also lost weight; and a fourth resident on a restorative eating plan was moved between tables, had delayed meal support, and ate only a few bites. The nutrition-at-risk record lacked recent notes for these residents, and staff interviews showed gaps in awareness of the weight loss and food preference details.
Failure to follow an ordered fluid restriction occurred for a resident with HF and ESRD on dialysis. The resident stated they were on a fluid restriction, but the MAR showed repeated discrepancies between day/night fluid entries and total consumed amounts, and an LPN said residents with fluid restrictions did not receive water pitchers while the total amount consumed was documented in the MAR; the DON stated licensed nurses were to follow orders and document clearly.
A resident with severe cognitive impairment and communication deficits experienced progressive weight loss from 108 lbs to 90.8 lbs over about five months, while the facility continued the same general supplement regimen and did not document food preference evaluations or a change to NEM, fortified foods, or calorie-dense meals. Meal records showed the resident usually ate only 0-25% of meals, and MNA findings documented worsening intake and malnutrition, but no follow-up recommendations were recorded. Staff confirmed the resident’s preferred foods were known but not documented, and no additional nutritional interventions were identified.
A resident with DM, cognitive communication deficit, dysphagia, and no teeth experienced significant weight loss after poor PO intake, refusal of snacks and supplements, and a non-individualized nutrition plan. Records showed the resident ate less than 25% of most meals, had a downward weight trend, and lost 11.6% of body weight within about 2 months. During observation, the resident ate only a few bites of lunch and said fruit was too hard to eat because they had no teeth.
Failure to monitor fluid restrictions for 3 residents with orders limiting intake. One resident with HF and dysphagia, another with HF, kidney disease, and edema, and a third with ESRD on dialysis and diabetes all had ordered fluid limits, but MARs did not show daily totals of fluids from nursing and dietary/kitchen. Observations found water pitchers at bedside for two residents, and staff interviews showed some CNAs were unaware of the restrictions while others relied on a blue cup sign and care plan notation.
Fluid restriction intake was not accurately monitored or totaled for two residents. One resident’s fluids were split between POC meal documentation and MAR entries, but the 24-hour total was not calculated and the resident exceeded the 1500 mL restriction on multiple days; several meal entries were left blank. For the other resident, nursing only initialed the fluid restriction on the MAR and did not record the amount provided, preventing calculation of the 24-hour intake total. The DON stated the orders should have identified dietary and nursing allotments and who would reconcile intake.
Incorrect Therapeutic Diet and Liquid Consistency Served: A resident with a hx of stroke, hemiplegia, cognitive impairment, and coughing/choking during meals was ordered a mechanical soft diet with ground meat and nectar thick liquids after a trial period. However, observations showed the resident still had regular ice water at bedside, was served juice that was not thickened, and was given food that was harder to chew than expected. Staff stated the diet change was not fully updated on the EHR/dashboard and the kitchen diet card remained incorrect.
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